André Mansoor
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Hey TF great to hear from you. I’ll address each question below:
- You are right. The jugular venous pulse (including the jugular venous pressure, or JVP) is a reflection of the right heart. However, the most common cause of right-sided heart failure is left-sided heart failure. The pressure and strain the LV experiences when it is failing will eventually back up and begin to affect the RV. So patients with decompensated left-sided HF will typically have the symptoms and signs that you describe (orthopnea, PND, S3, etc.) as well as elevated JVP. Each of these symptoms and signs is valuable when it comes to the overall assessment of the patient.
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The exact location of the lung/hemidiaphragm interface can vary from patient to patient. The lungs will be resonant to percussion while the hemidiaphragms will be dull. Normally the right hemidiaphragm is about 1-2 cm above the left. One thing you can do to be sure you are percussing the hemidiaphragm is to identify diaphragmatic excursion. To do this, have the patient breathe all the way out and hold it. Percuss down the back until the note changes from resonant to dull. Mark that spot. Next, have the patient breath all the way in and hold it. Repeat the percussion and mark the spot where the note changes. It should move down the chest between expiration and inspiration, the result of the hemidiaphragm moving down with inspiration. This will tell you for certain that you have identified the hemidiaphragm.
Hope this helps !
Thank you TF ! We have been recording patients for many years. In the beginning we used the Thinklabs digital stethoscope. We have since switched to the Eko Core digital stethoscope. The latter records with outstanding sound fidelity and is incredibly easy to work with (it uses bluetooth to record wirelessly to an app that you download on your smartphone or tablet, and you can visualize the phono in real time as it’s recording). You’re right, we are hoping that at some point in the near future we will be able to allow users to submit their own findings (images/video/audio) to be featured on the site (with credit). Stay tuned !
We talk a bit more about our recording devices on our “About Us” page: https://physicaldiagnosispdx.com/about-the-website/. It also includes links to the digital scopes.
Hi grayheel, thank you for this question. Yes there are additional strategies. Let’s review all of them. First of all, as you mentioned, split S1 is a higher-pitched sound, and is best heard with the diaphragm of the stethoscope. In contrast, S4 is a lower-pitched sound, best heard with the bell. The next strategy is timing. The split S1 sounds (M1 and T1) are closer together compared to the S4 and S1. In other words, the time between M1 and T1 is shorter than the time between S4 and S1. And finally, we should judge an extra heart sound “by the company it keeps”. Meaning, if you’re hearing an extra sound near S1 in a patient with risk factors for concentric LV hypertrophy, like aortic stenosis or longstanding hypertension, then that increases the likelihood that the sound you’re hearing is an S4. Or, on the other hand, if you’re hearing this sound in a patient with a right bundle branch block, then a split S1 becomes more likely. We always must consider context when interpreting physical findings.
Location on the chest wall over which the sound is heard best can often be helpful in other circumstances. It cannot help you in this situation as both split S1 and S4 are best heard in the region of the apex. However, location can help when it comes to differentiating a split S2 (best heard over base) from an S3 (best heard near the apex), for example.
Hope this helps. Let me know.
Hi Ashley – The ejection click is an extra transient sound that occurs near S1. So you’d hear two sounds close together (S1 + ejection click) followed by the S2 (three sounds total). It is on the differential for extra sounds near S1, along with split S1 and S4. A loud S1 or S2 on the other hand will be a single sound that is just louder than normal. Having said that, some patients might have a loud S1 or S2 AND an ejection click.
Does that make sense?
